Giant condyloma acuminatum or Buschke - Loewenstein tumor is a very rare disease usually located in the genital, anorectal, and perianal regions. It is locally invasive but in mostly cases displays a benign cytology on preoperative tissue sampling. Because of its low incidence little is known about treatment outcomes. Complete surgical excision is the treatment of choice. Different surgical methods have been applied to reach curability. To our knowledge such an advanced sized tumors in this localization has only been reported few times before with different surgical techniques being applied.
We describe a case of 56 years old female with 20 years persisting condyloma acuminatum progressing to a very huge dimensions perianal Buschke-Lowenstein tumor with one of the widest excision in the literature without the need for diverting stoma. The tumor size and its location determined the choice of treatment option and suspected prognosis for the patient outcome. Treatment was impeded by patient’s malnutrition. The giant Buschke - Loewenstein tumor was resected from the anus, perineum and gluteal areas. The large tissue losses were simultaneously covered with rotational skin and fatty subcutaneous tissue flaps, mobilized from neighboring gluteal and femoral areas. The circumferential part of the anal canal was covered with skin grafted from the mentioned flaps and it was attached to the anal mucosa. No protective stoma was formed. Despite temporary problems with healing of the covering skin flaps, full permanent coverage of the resection site has been achieved. Anal canal function has also improved within the time.
The patient with BLT must be very carefully clinical and imagistic investigated in order to detect the tumor visceral invasion and to establish the extension of the surgical procedure. There exists an extensive and time-consuming surgical procedure which allows to remove the giant anorectal Buschke - Loewenstein tumors with good function of the anorectum and without the necessity of diverting stoma creation.
Buschke; Loewenstein tumor; surgical intervention; simultaneous loss reconstruction
Buschke–Löwenstein tumour, also known as Giant condyloma acuminatum, is a rare, sexually transmitted disease that affects ano-genital region. BLT is a slow growing cauliflower-like tumour, locally aggressive and destructive. Human papillomavirus has been identified as an important contributory factor in the development of tumour.
PRESENTATION OF CASE
A 45 year uncircumcised male presented with complaints of cauliflower like growth on glans penis. Growth started as a small papule on the corona sulcus at 12 O’clock position 6 months back. Patient developed pain and dysuria due to compression of urethral meatus. Patient has history of multiple sexual partners.
BLT, first described by Buschke and Lowenstein in 1925. They observed a penile lesion that clinically resembled both common condyloma acuminata and squamous cell carcinoma, but differing from both of them regarding the biological behaviour and the histopathological appearance. GCA can be differentiated from ordinary condylomas by the characteristic “pushing” rather than “infiltrating” effect that tends to compress and displace the underlying tissue.
We have successfully treated a penile BLT with surgical excision and no relapse up to 6 months. Surgical excision could be considered an effective therapy in the treatment.
Giant condyloma acuminatum; Buschke–Löwenstein tumour; Surgical excision
A case of Buschke-Löwenstein's tumour presenting with urinary fistula is described. The large lesion in the subpreputial sac occluded the preputial opening and infiltrated beneath the skin of the shaft of the penis resulting in a fungating growth encasing the fistulous tract. The lesion responded well to 25% podophyllin, which is reportedly unusual.
Giant condyloma acuminatum or Buschke-Lowenstein tumour is a very rare disease which usually is located in the genital, anorectal, and perianal regions. It is regarded as a type of verrucous carcinoma occurring on anogenital mucosal surfaces where it is locally invasive but displays a benign cytology. We describe a case of a 24-year-old woman with persisting condyloma acuminata progressing to a large intra-abdominal Buschke-Lowenstein tumour. To our knowledge such an advanced stage has only been reported once before. The severity and extent of the tumour both determine the treatment and patient outcome. Treatment was impeded by cachexia, an immunosuppressive state after kidney transplantation and difficulties in establishing a reliable diagnose. Interferon treatment was started which initially led to tumour reduction but was complicated by an interferon-induced pancreatitis, pneumonia, and fasciitis necroticans resulting in death. We present a literature overview on the treatment options for a Buschke-Lowenstein tumour, with emphasis on interferon therapy, with all the advantages and disadvantages.
Penile verrucous carcinoma also known as Buschke-Löwenstein tumor in the genital region is an uncommon variant of penile carcinoma exhibiting slow, expansive growth. We present a case of a 63-year-old male who presented with a giant purulent penile mass causing urinary sepsis and angina. Regional lymph nodes were clinically negative and staging with CT scans of thorax and abdomen did not show any signs of lymph node or distant metastases. After resuscitation, radical penectomy was performed and a perineal urethrostomy was created. Histological examination revealed a Buschke-Löwenstein tumor of the penis with no invasion of corpus cavernosum and urethra.
Buschke–Löwenstein tumour (BLT) of the anogenitalia is a locally invasive, destructively growing verrucous carcinoma that does not metastasise. Histologically BLT resembles benign condylomata acuminata. Nevertheless, the tumour grows relentlessly and may rarely progress into squamous cell cancer (SCC).
A human immunodeficiency virus (HIV)-infected immunosuppressed patient developed (peri)anal warts accompanied by recurrent abscesses and fistulae. Histology revealed condylomata acuminata, and low-risk genital human papillomavirus (HPV) type 11b was detected. Six months later, the tumour had progressed into an ulcerated SCC that destroyed the rectum and perineum, with metastases to the inguinal lymph nodes. Whereas highly active antiretroviral therapy (HAART) effectively suppressed HIV replication, radiochemotherapy plus anti-EGFR antibody did not halt tumour progression, and the patient died from tumour-cachexia.
As far as is known, this is the first report demonstrating rapid progression of a BLT into a metastasising SCC in an HIV-infected patient.
Buschke Lowenstein tumour or giant condyloma acuminata is a rare entity with only less then 50 cases reported in English literature so far. No such case has been reported from the Kashmir valley. They are considered as intermediate lesions between simple condyloma acuminata and invasive squamous cell carcinoma. A 57-year-old heterosexual male presented with a giant perianal condyloma. The lesion was surgically excised completely. Postoperatively patient was put on topical 5-FU ointment. Patient is recurrence free 6 months after surgery. The giant condyloma acuminate is an aggressive tumour with propensity for recurrance and malignant transformation. Surgical excision is the treatment of choice. One such rare case is discussed with review of literature.
Condyloma acuminate; Buschke lowenstein; Perianal
Anogenital warts (condyloma acuminatum or venereal warts) are a common sexually transmitted disease in males and females. Common clinical treatment of anogenital warts is conservative, however, in extreme cases conservative therapy is insufficient and surgical excision is required. Giant condyloma acuminata (Buschke-Löwenstein tumour) is an extremely rare clinical type of genital wart, characterised by aggressive down growth into underlying dermal structures. A 55-year-old female presented with cauliflower-like growth over the anogenital and sacral region, earlier diagnosed as condyloma acuminatum which was resistant to conservative therapy. During the period between 2005 and 2008 the patient underwent five surgical procedures. Due to the size and location of the tumour, gynaecological and plastic surgeons were involved in the procedures. In addition, definitive histology examination identified a superficial vulvar carcinoma.
giant condyloma; Buschke-Löwenstein tumour; vulvar carcinoma; surgery
A 48-year-old man presented with multiple warts in groin for 1 year, which progressively increased in size. Local examination showed large vegetative growth in perianal area. Full thickness excision of involved skin and lesions was undertaken by electrocautery. Entire wound was left open to heal by secondary intention. Histopathological examination suggested Buschke-Löwenstein tumour. Postoperative follow-up for more than 2 years showed the absence of any recurrence.
Buschke-Löwenstein tumour; giant condyloma acuminatum; wide radical excision
The Improving Outcomes Guidance (IOG) for patients with carcinoma of the penis states that treatment should be provided supraregionally to populations of 4 million or greater who treat over 25 cases of penis cancer each year. This study assesses the impact of this guidance on the management and outcomes of patients with the disease in our region.
PATIENTS AND METHODS
We retrospectively compared the records of 44 patients with carcinoma of the penis treated in our institution between 1969 and 1990 with 101 patients treated between 2002 and 2006, i.e. after supraregional centralisation of the service.
There was no significant change in the stage or grade of the tumours. However, the results show that, in modern times, there was a significant increase in the amount of penis-preserving and nodal surgery as well as a fall in mortality. The improved survival is greatest in patients with poorly-differentiated disease who may, therefore, have benefited from aggressive nodal surgery.
The centralisation of surgery for carcinoma of the penis results in improved outcomes both in terms of preservation and improved survival and this supports the IOG guidance.
Improving Outcomes Guidance; Penis cancer; Penis preservation; Survival
We consider approaches to brain dynamics and function that have been claimed to be Darwinian. These include Edelman’s theory of neuronal group selection, Changeux’s theory of synaptic selection and selective stabilization of pre-representations, Seung’s Darwinian synapse, Loewenstein’s synaptic melioration, Adam’s selfish synapse, and Calvin’s replicating activity patterns. Except for the last two, the proposed mechanisms are selectionist but not truly Darwinian, because no replicators with information transfer to copies and hereditary variation can be identified in them. All of them fit, however, a generalized selectionist framework conforming to the picture of Price’s covariance formulation, which deliberately was not specific even to selection in biology, and therefore does not imply an algorithmic picture of biological evolution. Bayesian models and reinforcement learning are formally in agreement with selection dynamics. A classification of search algorithms is shown to include Darwinian replicators (evolutionary units with multiplication, heredity, and variability) as the most powerful mechanism for search in a sparsely occupied search space. Examples are given of cases where parallel competitive search with information transfer among the units is more efficient than search without information transfer between units. Finally, we review our recent attempts to construct and analyze simple models of true Darwinian evolutionary units in the brain in terms of connectivity and activity copying of neuronal groups. Although none of the proposed neuronal replicators include miraculous mechanisms, their identification remains a challenge but also a great promise.
neural Darwinism; neuronal group selection; neuronal replicator hypothesis; Darwinian neurodynamics; Izhikevich spiking networks; causal inference; price equation; hill-climbers
Craving for alcohol is a highly controversial subjective construct and may be clarified by Loewenstein's visceral theory, which emphasizes craving's behavioral effects on the relative value of alcohol. Based on the visceral theory, this study examined the effects of a craving induction on the relative value of alcohol as measured by a behavioral choice task. In addition, based on previous evidence of its role in the expression of craving, the influence of DRD4 VNTR genotype (DRD4-L vs. DRD4-S) was also examined.
Thirty-five heavy drinkers (54% male; 31% DRD4-L) were randomly assigned to receive either a craving induction (exposure to personally relevant alcohol cues) or a control induction (exposure to neutral cues), which was followed by an alcohol-money choice task. Participants were assessed for craving and positive/negative affect throughout the procedure, and relative value of alcohol was derived from participant choices for alcohol versus money. DRD4 VNTR status was assessed retrospectively via buccal samples using previously established protocols.
Factorial analysis of the craving induction revealed that it was associated with significant increase in craving (p < .001), but not greater relative value of alcohol. Factorial analyses including DRD4 VNTR genotype of did not suggest an influence on reactivity to the craving induction, although this analysis was substantially compromised by small cell sample sizes. Continuous analyses revealed that craving was significantly associated with the relative value of alcohol (p < .05) and possession of the DRD4-L allele further amplified this relationship (p < .001).
These results are interpreted as generally supporting Loewenstein's visceral theory of craving and evidence of a functional role of DRD4 VNTR genotype in the expression of craving for alcohol. Methodological limitations, mechanisms underlying these findings, and future directions are discussed.
Carcinoma cuniculatum of the penis is an extremely rare variant of squamous cell carcinoma characterized by an endophytic deeply branching and burrowing growth pattern. One documented case series demonstrated afflicted patients ranging in age from 73–83 years with the tumour located on the glans penis, coronal sulcus or foreskin. We report a case of a 55-year-old with disease located on the ventral aspect of the shaft of the penis. The tumour was invasive into the deep dermal connective tissue, comparatively superficial to all previous documented cases. He subsequently underwent a partial penectomy. The case is discussed with a brief review of the literature.
A 73-year-old male presented with a 3-month history of two penile masses: one on the shaft and one on the glans penis. Both lesions were poorly defined, fixated and without tenderness. The sizes were 1.0 × 1.0 × 1.0 cm and 1.2 × 1.5 × 1.5 cm, respectively. The patient underwent lumpectomy of the glans penis; we confirmed malignant lymphoma of the glans penis (B-cell derived; diffused large B-cell) by postoperative pathological examinations. CHOP (cyclophosphamide-hydroxydaunorubicin-oncovin-prednisone) chemotherapy was administered. The patient was tumour-free at the 33-month follow-up.
To highlight the salient features of metastatic malignancies involving the penis, with special reference to the primary tumour sites, metastatic mechanisms, clinical features, differential diagnosis, treatment and prognosis.
A comprehensive search of the literature was performed using MEDLINE and EMBASE, using the keywords 'penis', 'secondary malignancy', 'metastasis' and 'malignant priapism' to identify reviews and case reports of secondary penile malignancy. A case of rare clinical presentation of metastatic penile lesion is presented along with the review of the literature.
Secondary malignancy of the penis is a rare clinical entity, despite the rich vascularisation of this organ. The majority of metastatic lesions take their origin from the neighbouring genito-urinary organs, mainly prostate and bladder. These lesions are often associated with disseminated malignancy and hence have a poor outcome. Nodular or ulcerative lesions involving the corpora cavernosa or priapism are the main modes of clinical presentation. In most cases, only palliative or supportive therapy is indicated.
Giant anal condyloma also called Buschke–Löwenstein tumor is a rare sexually transmitted disease involving anogenital region with potential malignant degeneration into invasive squamous carcinoma. Complete surgical excision is the treatment of choice and often wide wounds are necessary to reach clear margins and prevent recurrence.
PRESENTATION OF CASE
The authors present two cases treated with an S-plasty rotating and a bilateral house advancement flap respectively with good functional result.
Giant anal condyloma also called Buschke–Löwenstein tumor is a large exophytic, cauliflower-like mass that is characterized by local aggressive behavior. Immunosuppression favors rapid growth of the condylomas and increases the risk of their malignant transformation. In limited lesions primary excision can be safely performed leaving wounds open to granulate while in more extensive lesions flap or skin graft coverage is preferable to decrease the length of recovery and minimize risk of severe anal stricture. Abdominoperineal resection should be performed for more extensive lesions with deep invasion, malignant transformation or tumor recurrence.
Giant anal condyloma also called Buschke–Löwenstein is a rare pathology with mainly sporadic single center experience reported in literature. Surgical complete excision remains the best treatment although elevate should be eventual recurrence. No sufficient data are available to recommend any medical treatment such as interferon, radiotherapy or chemotherapy.
Giant condyloma; Buschke–Löwenstein tumor; S-plasty rotating flap; House advancement flap
Cancer of the penis is a rare tumour in Europe and mainly affects the elderly patient population. The aim of this paper was to analyse and study the characteristics of this tumour, in our patient population.
Materials and Methods. A retrospective study was conducted on penile tumours diagnosed and treated in the Urology Department of the Hospital Universitario La Paz, Madrid, in the last ten years.
Results. A total of 34 patients were diagnosed and treated. The mean age at presentation was 71.27 years. The mean time between symptoms and the first consultation was 12.54 months with a median of 6 months. The most common form of presentation was balanoposthitis (32%) and the most common site in our series was the glans. Partial penectomy was performed in 22 cases, total amputation in 8, and local excision in 3. Discussion. Carcinoma of the penis is a pathology which mostly affects elderly patients; in our series, the highest incidence was observed in patients in the group aged 75–84 years. The most common histological type was epidermoid carcinoma in its various forms of presentation. We recorded a mortality of 23%. Conclusion. Penile carcinoma is a rare pathology which affects elderly persons and is diagnosed late.
The aim of the study was to describe the shear wave velocity (SWV) values of the penis by virtual touch tissue quantification (VTTQ) and to examine the clinical usefulness of this procedure in evaluation of the rigidity changes in penile erection.
Patients and methods.
VTTQ was performed in 37 healthy volunteers. In the course of erection, SWV values of glans penis, corpus penis and radix penis were quantified and grades of erection were documented. The SWV values at different grades of erection were compared.
The axial and radial SWV values of glans penis, corpus penis and radix penis all significantly decreased from Grade 0 to Grade 4 of erection. At Grade 4, they were less than one-third of that at Grade 0 (axial direction: 0.79 ± 0.13 vs. 2.79 ± 0.32 for glans penis, P<0.001; 0.77 ± 0.19 vs. 2.84 ± 0.30 for corpus penis, P<0.001 and 0.76 ± 0.15 vs. 2.81 ± 0.34 for radix penis, P<0.001; radial direction: 0.82 ± 0.15 vs. 2.83 ± 0.31 for glans penis, P<0.001; 0.79 ± 0.18 vs. 2.81 ± 0.27 for corpus penis, P<0.001 and 0.81 ± 0.16 vs. 2.82 ± 0.33 for radix penis, P<0.001).
VTTQ can provide numerical measurements of penile rigidity and can effectively and sensitively indicate the axial and radial rigidity changes in penile erection, which provide a new approach to assessing the erectile function.
virtual touch tissue quantification; axial and radial rigidity; erection; shear wave velocity
Fibroepithelial polyps are rare benign tumours of the glans penis; there are only a few reported cases. The pathogenesis is unknown. However, they have been linked with chronic condom catheter use or prior penile surgery. We report a case of a 62-year-old man with a large fibroepithelial polyp of the glans penis of 11 years duration, which was not associated with condom catheter use or prior surgery. The mass was large, measuring 7 × 5 × 3 cm. Fibroepithelial polyps have been reported in a range of genito-urinary sites in males and females, adults and children, and in rare cases may be associated with malignant transformation. They should be considered in the differential diagnosis of both cutaneous and mucosal genitourinary lesions.
Primary leiomyosarcoma of the penis is a very rare tumour. Only 46 cases have been reported in the English medical literature. We are presenting this case of a 59-year-old patient with a ulceroproliferative growth in his penis. Histopathology was a high grade spindle cell sarcoma, which was proved by immunohistochemistry to be a leiomyosarcoma.
Spindle cell sarcoma; Immunohistochemistry; Leiomyosarcoma
Epithelioid hemangioma is a rare benign vascular tumour that atypically involves the penis and usually presents as a painful nodule. A 35-year-old man presented with a 5-month history of painful erections without a clinically apparent lesion or deformity. Magnetic resonance imaging (MRI) with pharmacologically induced erection demonstrated a 1.3-cm nodular lesion deep to the skin at the base of his penis. Following local excision of the lesion, which was diagnosed as an epithelioid hemangioma, the patient was symptom free. This case demonstrates a rare etiology of painful erections with a unique presentation. To the authors’ knowledge, it is also the first report of MRI with intracavernosal injection of trimix to assess for a specific cause of painful erections.
Verrucous carcinoma of the skin and mucosa is an uncommon type of well-differentiated squamous cell carcinoma. When it is present in the genitoanal region the term used is Buschke-Lowenstein tumor. The human papillomavirus seems to be implicated in its aetiology. Treatment is controversial. Topical chemotherapy, radiotherapy, immunotherapy and radical surgery have been employed.
We report a rapidly progressing penile verrucous carcinoma which was treated sucessfuly with conservative surgery and CO2 laser.
Treatment with CO2 laser in combination with conservative surgery may be a therapeutic option in Buschke-Lowenstein tumor.
condylomata acuminata; lasers; penile neoplasms; squamous cell carcinoma; verrucous carcinoma
While paraneoplastic syndromes in patients with malignant and metastasizing tumors are common, they are rarely associated with skin tumors showing predominantly local growth patterns. This case report relates to a patient with giant condyloma acuminatum, also called Buschke-Löwenstein tumor, with paraneoplastic hypercalcemia, who was successfully treated with conservative treatment.
The patient in question is a 48-year-old German man with a giant periscrotal tumor. Before and during the therapy, two episodes of symptomatic hypercalcemia occurred, which were successfully treated by bisphosphonates, intravenous fluids and diuretics. No evidence of lytic bone affection was found.
Paraneoplastic hypercalcemia may occur in patients who have a Buschke-Löwenstein tumor. For patients, where surgery is not an option, established medical therapies like bisphosphonates may be useful in addition to diuretics and infusions.
Paraneoplastic hypercalcemia; Buschke-Löwenstein tumor; Giant condyloma acuminatum
Verrucous carcinoma of the external genitalia and perianal region is a rare variant of well-differentiated squamous cell carcinoma. It has been reported to have limited metastatic potential.
We report the case of a 54 year-old Moroccan man who presented with locally advanced giant condyloma acuminatum (Buschke–Löwenstein tumor) after prolonged intervals of neglect (approximately 10 years). The disease covered his suprapubic, external genitalia and perianal region. It was locally aggressive with extensive tissue destruction. After a biopsy of the lesion, the diagnosis of verrucous carcinoma was confirmed. He initially received chemoradiotherapy, followed by extensive local excision, but he developed septic shock and died a few days later.
The purpose of this case report is to present a case of verrucous carcinoma arising in an extensive giant condyloma acuminatum (Buschke–Löwenstein tumor) and discuss the literature on its diagnosis and management.
Buschke–Löwenstein tumor; Chemoradiotherapy; Condyloma acuminatum; Human papillomavirus; Verrucous carcinoma
A 58-year-old male patient presented with an anorectal verrucous carcinoma, also
known as Buschke–Lowenstein tumor. Clinically, the lesion of the patient
best resembled giant condyloma acuminatum with a cauliflower-like appearance.
The diagnosis was confirmed with biopsy and an abdominoperineal resection was
performed. The perineal defect was reconstructed with bilateral gluteal
musculocutaneous V-Y advancement flap. Both functional and cosmetic results
6 years after the operation were excellent. To date, no recurrence has
been noted. As long as one is aware of its existence and of its characteristic
appearances, the Buschke–Lowenstein tumor is fairly easily diagnosed.
The treatment of choice remains surgical resection, and adequate follow-up is
Verrucous carcinoma; Buschke–Lowenstein tumor; Giant condyloma acuminatum; Abdominoperineal resection; V-Y advancement flap